What is depression in children and teens?

Depression is a serious mood disorder that can take the joy from a
child's life. It is normal for a child to be moody or sad from time to time.
You can expect these feelings after the death of a pet or a move to a new city.
But if these feelings last for weeks or months, they may be a sign of
depression.

Experts used to think that only adults could get
depression. Now we know that even a young child can have depression that needs
treatment to improve. As many as 2 out of 100 young children and 8 out of 100 teens
have serious depression.1

Still, many
children don't get the treatment they need. This is partly because it can be
hard to tell the difference between depression and normal moodiness. Also,
depression may not look the same in a child as in an adult.

If
you are worried about your child, learn more about the symptoms in children.
Talk to your child to see how he or she is feeling. If you think your child is
depressed, talk to your doctor or a counselor. The sooner a child gets
treatment, the sooner he or she will start to feel better.

What are the symptoms?

A child may be depressed if
he or she:

Is irritable, sad, withdrawn, or bored most of the time.

Does not take pleasure in things he or she used to enjoy.

A child who is depressed may also:

Lose or gain weight.

Sleep too
much or too little.

Feel hopeless, worthless, or guilty.

Have trouble concentrating, thinking, or making decisions.

Think about death or suicide a lot.

The symptoms of depression are often overlooked at first.
It can be hard to see that symptoms are all part of the same problem.

Also, the symptoms may be different depending on how old the child is.

Both very young children and grade-school children may lack energy and
become withdrawn. They may show little emotion, seem to feel hopeless, and have
trouble sleeping. Often they will lose interest in friends and activities they liked before. They may complain of headaches or stomachaches. A child may be more anxious or clingy with caregivers.

Teens may sleep a lot or
move or speak more slowly than usual. Some teens and children with severe depression may see or hear
things that aren't there (hallucinate) or have false beliefs
(delusions).

Depression can range from mild to severe. A child who
feels a little "down" most of the time for a year or more may have a milder,
ongoing form of depression called
dysthymia (say "dis-THY-mee-uh"). In its most severe
form, depression can cause a child to lose hope and want to die.

Whether depression is mild or severe, there are treatments that can help.

What causes depression?

Just what causes
depression is not well understood. But it is linked to a problem with activity levels in certain parts of the brain as well as an imbalance of
brain chemicals that affect mood. Things that may
cause these problems include:

Stressful events, such as changing schools,
going through a divorce, or losing a close family member or friend.

How is depression diagnosed?

To diagnose
depression, a doctor may do a physical exam and ask questions about your child's
past health. You and your child may be asked to fill out a form about your child's symptoms.
The doctor may ask your child questions to learn more about how he or she
thinks, acts, and feels.

Some diseases can cause symptoms that
look like depression. So the child may have tests to help rule out physical
problems, such as a
low thyroid level or
anemia.

How is it treated?

Usually one of the first steps
in treating depression is education for the child and his or her family.
Teaching both the child and the family about depression can be a big help. It
makes them less likely to blame themselves for the problem. Sometimes it can
help other family members see that they are also depressed.

Counseling may help the child feel better. The type of
counseling will depend on the age of the child. For young children,
play therapy may be best. Older children and teens may
benefit from
cognitive-behavioral therapy. This type of counseling
can help them change negative thoughts that make them feel bad.

Medicine may be an option if the child is very depressed. Combining
antidepressant medicine with counseling often works best. A child with severe
depression may need to be treated in the hospital.

There are some
things you can do at home to help your child start to feel better.

Encourage your child to get regular exercise, spend time with supportive friends, eat
healthy foods, and get enough sleep.

See that your child takes
any medicine as prescribed and goes to all follow-up appointments.

Make time to talk and listen to your child. Ask how he or she is
feeling. Express your love and support.

Remind your child that
things will get better in time.

What should you know about antidepressant medicines?

Antidepressant medicines often work well for children who are depressed. But there are some important things you should know about these medicines.

Children who take antidepressants should be
watched closely. These medicines may increase the risk that a child will think
about or try suicide, especially in the first few weeks of use. If your child
takes an antidepressant, learn the warning signs of suicide, and get help right
away if you see any of them. Common warning signs include:

Talking, drawing, or writing about death.

Giving away belongings.

Withdrawing from family and
friends.

Having a plan, such as a gun or pills.

Your child may start to feel better after 1 to 3 weeks of
taking antidepressant medicine. But it can take as many as 6 to 8 weeks to see
more improvement. Make sure your child takes antidepressants as prescribed and
keeps taking them so they have time to work.

A child may need to
try several different antidepressants to find one that works. If you notice any
warning signs or have concerns about the medicine, or if you do not notice any
improvement by 3 weeks, talk to your child's doctor.

Do not let a
child suddenly stop taking antidepressants. This could be dangerous. Your
doctor can help you taper off the dose slowly to prevent problems.

Cause

Depression is
thought to be caused by an imbalance of chemicals called
neurotransmitters that send messages between nerve
cells in your brain. Some of these chemicals, such as serotonin, help regulate
mood. If these mood-influencing chemicals get out of balance, depression or
other mood disorders can result. Experts have not yet identified why
neurotransmitters become imbalanced. They believe a change can occur as a
response to stress or illness. But a change may also occur with no obvious
trigger.

There are several things known to increase the chances
that a young person may become depressed.

Depression runs in families. Children and teens
who have a parent with depression are more likely to develop depression
than children with parents who are not depressed.
Experts believe that both inherited traits (genetics) as well as living with a
parent who is depressed can cause depression.

Depression in
children and teens may be linked to stress, social problems, and unresolved
family conflict. It can also be linked to traumatic events, such as violence,
abuse, or neglect.

Certain thinking patterns and coping styles may make some children and teens more likely to develop depression.

Children or teens who have long-term or serious
medical conditions, learning problems, or behavior problems are more likely to
develop depression.

Some medicines can trigger depression,
such as steroids or narcotics for pain relief. As soon as the medicine is
stopped, symptoms usually disappear.

Alcohol and drug abuse may trigger depression in children and teens.

Symptoms

The symptoms of depression are often subtle at first. They may occur suddenly or happen slowly over time. It can be hard to
recognize that symptoms may be connected and that your child might have
depression.

Physical symptoms

Unexplained aches and pains, such as headaches or stomach
pain

Trouble
sleeping, or sleeping too much

Changes in eating habits that lead
to weight gain or loss or not making expected weight gains

Constant tiredness, lack of
energy

Body movements that seem slow, restless, or agitated

Mental or emotional symptoms

Irritability or temper
tantrums

Difficulty thinking and making decisions

Having low
self-esteem, being self-critical, and/or feeling that others are unfairly critical

Feelings of guilt and
hopelessness

Social withdrawal, such as lack of interest in
friends

Anxiety, such as worrying too much or fearing
separation from a parent

Thinking about death or feeling suicidal

It's important to watch for
warning signs of suicide in your child or teen. These
signs may change with age. Warning signs of suicide in children and teens may
include preoccupation with death or suicide or a recent breakup of a
relationship.

Depression can have symptoms that are similar to those caused by
other conditions.

For
example, grieving (bereavement) is a normal response to loss, such as the
death of a family member or even the death a pet, loss of a friendship, or
parents' divorce. After a severe loss, a child may remain sad for a longer
period of time.

But when these emotions do not go away or begin to interfere
with the young person's life, he or she may need treatment.

Bipolar disorder

Some children who are first diagnosed with
depression are later diagnosed with bipolar disorder. Children or teens with
bipolar disorder have extreme mood swings between depression and bouts of
mania (very high energy, agitation, or irritability).

It can be hard to tell the difference
between
bipolar disorder and depression. It is common for
children with bipolar disorder to first be diagnosed with only depression and
later to be diagnosed with bipolar disorder after a first manic episode.
Although depression is part of the condition, bipolar disorder requires
different treatment than depression alone.

Like depression, bipolar disorder
runs in families. So be sure to tell your doctor if your child has a family
history of bipolar disorder. For more information on bipolar disorder, see the
topic Bipolar Disorder in Children and Teens.

What Happens

At first, depression in a
child or teen may appear as irritability, sadness, or sudden, unexplained
crying. He or she may lose interest in activities enjoyed in the past or may
feel unloved and hopeless. He or she may have problems in school and become
withdrawn or defiant.

An episode of depression lasts an average of 8 months.1 Even with successful treatment, as many as 40 out of 100 children
with depression will have another episode within a few years.2

Less than half of children and teens with depression receive treatment.3 This may be partly due to the old belief that young people don't get depression.

Also, teens often do not seek help for depression. They may think feeling bad is normal, or they may blame something else (or themselves) for their symptoms. Or they may not know where to go for help. Tell your child to ask for help if he or she feels bad. And let your child know who to go to for help with depression or other problems.

Drugs and alcohol

Some teens will
have
alcohol or drug use problems along with
depression. When this happens, depression is harder to treat, and it can take longer for treatment to work. Drug or alcohol use also increases the risk of suicide.

Early diagnosis and treatment of
depression and good communication with your child can help prevent substance
abuse. For more information about substance abuse in young people, see the
topic
Teen Alcohol and Drug Abuse.

These
problems may occur before a young person becomes depressed. Some children with
depression develop serious behavior problems (conduct disorder), often after becoming depressed. If your child has one of
these disorders, it may require treatment along with depression.

Children
and teens with depression are also at a higher risk for problems
such as:

Poor school or job
performance.

Problems in relationships with peers and family
members.

Early pregnancy.

Physical illness.

Treatment in the hospital

For severe depression, your child may need to be
hospitalized, especially if he or she is out of touch with reality (psychotic) or is having thoughts of suicide.

Relapse

During treatment for depression, make sure that your child
takes medicines and attends counseling appointments as directed, even if he or
she feels better. A common cause of
relapse is stopping treatment too soon.

It is extremely important that you take all threats of suicide seriously and seek immediate treatment for your child or teenager. If you are a child or teen and have these feelings, talk with your parents, an adult friend, or your doctor right away to get some help. If your child is suicidal, call 911 or other emergency services immediately.

What Increases Your Risk

Several things increase a
young person's chance of developing
depression. These include:

Having a parent or immediate family member who is depressed. This
is the most important risk factor for depression. Children or teens who have a
parent with depression are up to 3 times more likely to develop
depression.

Having been depressed before, especially if depression
first occurred at an early age.

When To Call a Doctor

Call 911, the national suicide hotline at 1-800-273-TALK (1-800-273-8255), or other emergency services right away if:

Your child is thinking seriously of committing suicide or has recently tried to commit suicide. Serious signs include these thoughts:

Has decided how to kill himself or herself, such as with a weapon or pills.

Has set a time, place, and means to do it.

Thinks there is no other way to solve the problem or end the pain.

Your child feels he cannot stop from hurting himself or someone else.

Call a doctor right away if:

Your child hears voices.

Your child has been thinking about death or suicide a lot but does not have a plan to commit suicide.

Your child is worried a lot that the feelings of depression or thoughts of suicide are not going away.

Seek care soon if:

Your child has symptoms of depression, such as:

Feeling sad or hopeless, or being irritable.

Not enjoying anything.

Often complaining of stomachaches or headaches.

Having trouble with sleep.

Feeling guilty.

Feeling anxious or worried.

Your child has been treated for depression for more than 3 weeks but is not getting better.

Who to see

Treatment for
depression may involve professional
counseling, medicines, education about depression for
your child and your family, or a combination of these. It is important that
your child establish a long-term and comfortable relationship with the care
providers for the treatment of depression.

Your child may be
diagnosed and treated by more than one health professional, including a:

Exams and Tests

Your doctor or another health
professional will evaluate and diagnose
depression in your child by asking questions about
your child's medical history and conducting tests to find out if symptoms are
caused by something other than depression. Your child may be given a physical
exam or blood tests to rule out conditions such as
hypothyroidism and
anemia. Your child may be asked to complete a
mental health assessment, which tests his or her
ability to think, reason, and remember.

You may be asked to help
complete a pediatric symptom checklist, a brief screening questionnaire that
helps to diagnose depression or other psychological problems in children. Also,
your child may be asked to take a short written or verbal test for depression.

Sometimes a more thorough evaluation may be needed to fully
assess your child's depression. Interviews may be conducted with the parents or
with other people who know the young person well. Specific information may be
obtained from the child's teachers or from social service workers.

Counseling

Medicines

Medicines used to treat childhood
depression include several types of drugs called antidepressants.

An important part of treatment is making
sure that your child takes medicines as prescribed. Often people who feel better
after taking an antidepressant for a period of time may feel like they are
"cured" and no longer need treatment. But when medicine is stopped too early, symptoms
usually return. So it is important that your child follows the treatment
plan.

The U.S. Food and Drug Administration (FDA) has issued an advisory on antidepressant medicines and the risk of suicide. Talk to your doctor about these possible side effects and the warning signs of suicide

Before prescribing medicine, your doctor will check your child for possible suicidal
thoughts by asking a few questions. See a list of
questions your doctor may ask your child.

Education

Education of your child and family members can be provided by
a doctor either informally or in family therapy. Some of the most important
things that your child and family members can learn include:

Knowing how to make sure a child is following
a treatment plan, such as taking medicine correctly and going to counseling
appointments.

Learning ways to reduce stress caused by living with
someone who has depression.

Knowing the signs of a relapse and what
to do to prevent depression from recurring.

Knowing the signs of
suicidal behavior, how to evaluate their seriousness, and how to
respond.

Learning how to identify signs of a manic episode, which
is a bout of extremely high mood and energy, or irritability that is a sign of
bipolar disorder.

Seeking treatment if you
are a parent with depression. If a parent's depression goes
untreated, it may interfere with the recovery of the child.

Additional treatment

Your child may need treatment for other disorders that may be causing ongoing symptoms, such as:

If
your child is depressed, consider removing all guns and potentially fatal
medicines from your home, especially if your child has shown any warning signs
of suicide. Although overdosing on medicine is the most common way that teens
attempt suicide, your child is at higher risk for dying by suicide if you
have a gun in your home, particularly if it is easy to get to it or if you
store it loaded.6

Prevention

It is difficult to prevent a first episode
of
depression. But it may be possible to prevent or
reduce the severity of future episodes of depression (relapses).

There is some evidence that if a child receives
cognitive-behavioral therapy (CBT) in a group setting,
it can help prevent or delay the onset of depression in a child or teen whose
parent has a history of depression (which puts the child at greater risk for becoming
depressed).7

Make sure that your child has
a good social support system, both at home and through teachers, other family
members, and friends who can provide encouragement and
understanding.

Learn to recognize early symptoms of depression, and
seek immediate diagnosis and treatment if they occur.

Some schools provide educational materials and group therapy
opportunities to those at high risk for depression, such as those who
have family conflict or problems with peers.

Home Treatment

Do everything possible to provide a supportive family environment. Love,
understanding, and regular communication are some of the most important things
you can provide to help your child cope with
depression.

In addition to having a
positive home life, staying in professional counseling, and taking medicines as
prescribed, good lifestyle habits can help reduce your child's symptoms of
depression. Encourage your child to:

Avoid alcohol and illegal
drugs, nonprescription medicines, herbal therapies, and medicines that have not
been prescribed (because they may interfere with the medicines used to treat
depression).

Get enough sleep. If your child has problems sleeping,
he or she might try:

Going to bed at the same time every
night.

Keeping the bedroom dark and quiet.

Not
exercising after 5:00 p.m.

Eat a
balanced diet. If your child lacks an appetite, try to
get him or her to eat small snacks rather than large meals.

Spend time with supportive friends.

Be
hopeful about feeling better. Positive thinking is very important in recovering
from depression. It is difficult to be hopeful when you feel depressed, but
remind your child that improvement occurs gradually and takes time.

If you notice any
warning signs of suicide (such as aggressive or
hostile behavior, excessive thoughts about death, or detachment from reality),
seek professional help immediately by calling either your child's doctor, a
professional counselor, or a local mental health or emergency service.
Call 911 if you feel your child is in immediate danger.

Medications

Although experts believe that, for many children with depression, the benefits of medicine outweigh the risks, research on antidepressant medicine in children is limited. The long-term effects and safety of medicines used to treat depression in children and teens are still unknown.

You may have heard about concerns regarding a possible connection between antidepressant medicines and suicidal behavior. The U.S. Food and Drug Administration (FDA) has issued advisories about this issue.

Especially during the
first few weeks of treatment with an antidepressant, there is a possible
increase in suicidal feelings or behavior. A child beginning antidepressant
treatment should be watched closely. But children with untreated depression
are also at an increased risk for suicide. So it is important to carefully
weigh all of the risks and benefits of antidepressant medicine.

What to think about

Antidepressant medicines such as
fluoxetine (Prozac, for example) can be effective in treating depression, but
it may take 1 to 3 weeks before your child starts to feel better. It can take
as many as 6 to 8 weeks to see more improvement. Make sure your child takes
antidepressant medicines as prescribed and keeps taking them so they have time
to work. If you have any questions or concerns about the medicine, or if you do
not notice any improvement by 3 weeks, talk to your child's doctor.

SSRIs may also be effective in treating other conditions such as
anxiety.

Your child may have to try
several medicines or different dosages before the most effective treatment is discovered. After the
right medicine and dosage is found, your child may need to continue taking the medicine
for several months or longer after the symptoms of depression have subsided, to
prevent depression from occurring again.

Some children who are
first diagnosed with depression are later diagnosed with
bipolar disorder, which has symptoms that cycle from
depression to
mania (very high energy, often with euphoria,
agitation, irritability, risk-taking behavior, or impulsiveness). If your child
or teen has bipolar disorder, a first episode of mania can happen
spontaneously. But it can also be triggered by certain medicines such as
stimulants or antidepressants. That is why it is very important to tell your
child's doctor about any family history of bipolar disorder and to watch your
child closely for signs of manic behavior. For more information about bipolar
disorder in young people, see the topic
Bipolar Disorder in Children and Teens.

FDA advisory

The U.S. Food and
Drug Administration (FDA) has issued an
advisory on antidepressant medicines and the risk of
suicide. The FDA does not recommend that people stop using these medicines. Instead, a person taking antidepressants should be watched for
warning signs of suicide. These signs may include talking about death or suicide and giving away belongings. This is especially important at the beginning of treatment or when doses are changed.

Other Treatment

Complementary medicine is sometimes used for
depression in adults. But there is
no evidence that these therapies are safe for use by children or teens.2 They can interfere with other
medicines, such as antidepressants. Always tell your doctor if you are using any complementary therapies.

Other treatment choices

Types of counseling most often used to treat
depression in children and teens are:

Family therapy, which provides a place for the whole
family to express fears and concerns and learn new ways of getting along.

Play therapy, which is used with young children or
children with developmental delays to help them cope with fears and anxieties.
But there is no proof that this type of treatment reduces symptoms of
depression.

Electroconvulsive therapy (ECT) may be an effective treatment for a teen
or older child who is severely depressed or does not respond to other
treatment, although this treatment is rarely used for children and teens. Even
though it is an effective treatment for adults with major depression, there are
currently no long-term studies on the safety of using ECT.2

What to think about

The U.S. Food and Drug
Administration (FDA) has approved the vagus nerve stimulator (VNS) implant for
treatment of depression in adults. This device may be used when other
treatments for depression have not worked.

A generator the size
of a pocket watch is placed in the chest. Wires go up the neck from the
generator to the vagus nerve. The generator sends tiny electric shocks through
the vagus nerve to that part of the brain that is believed to play a role in
mood.

More study is needed to see how well this works in children who have depression.

U.S. Preventive Services Task Force (2009). Screening for Major Depressive Disorder in Children and Adolescents: Recommendation Statement. Available online: http://www.uspreventiveservicestaskforce.org/uspstf09/depression/chdeprrs.htm.

U.S. Preventive Services Task Force (2009). Screening for Major Depressive Disorder in Children and Adolescents: Recommendation Statement. Available online: http://www.uspreventiveservicestaskforce.org/uspstf09/depression/chdeprrs.htm.

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